September 2022 AI Alert

Double-down on Single Diagnosis Care Management Codes  

Care management services are defined as the management and support services provided personally by the physician or by their clinical staff (under the direction of a physician or other qualified healthcare professionals) to a patient residing at home, in a domiciliary, rest home, or assisted living facility. The billing clinician provides or oversees the management and/or coordination of care management services which include:

• • • Establishing, implementing, revising, or monitoring the care plan
    • Coordinating the care of other professionals and agencies
    • Educating the patient or caregiver about the patient’s condition(s), care plan, and prognosis.

Care management includes the following three categories of care services: chronic, complex or principal care management.

Chronic Care Management:

• • • Requires two or more chronic conditions or episodic health conditions which are expected to last for at least the next twelve months or until the death of the patient.
    • These chronic conditions must put the patient at a significant risk of death, acute exacerbation/decomposition, or functional decline.
    • Comprehensive care plan established, implemented, revised, or monitored.

Code 99490 : is used to report the first 20 minutes of clinical staff time directed by the physician, or another qualified healthcare professional per calendar month

Code + 99439: is used to report each additional 20 minutes of clinical staff time directed by the physician or another qualified healthcare professional per month (list separately in addition to the primary code)

Code 99491: use this code to report the first 30 minutes of services personally provided by the physician or other qualified healthcare professional per month

Code + 99437: is used to report each additional 30 minutes of service personally provided by the physician or other qualified healthcare professional, per month

Complex Care Management:

• • • Requires two or more chronic conditions expected to last at least 12 months or until the death of the patient.
    • Chronic conditions that place the patient at significant risk of death, acute exacerbation/decomposition, or functional decline.
    • Comprehensive care plan established, implemented, revised, or monitored.
    • Moderate or high complexity of medical decision making.

Code 99487 : use this code to report the first 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month

Code + 99489:  is used to report each additional 30 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per month

NOTE: if the physician personally performs the clinical staff activities their time may be counted toward the required clinical staff time to meet the elements of the code.

Principal Care Management:

Focuses on the medical and/or psychological needs manifested by:

• • • a single, high-risk disease, expected to last at least 3 months that place the patient at significant risk of hospitalization, acute exacerbation/decompensation, functional decline, or death.
    • the condition requires the development, monitoring, or revision of a disease-specific care plan.
    • the condition requires frequent adjustments to the medication regime and/or the management of the condition is unusually complex due to comorbidities.
    • ongoing communication and care coordination between relevant practitioners furnishing care.

Code 99424 : use this code to report the first 30 minutes provided by the physician or other qualified health care professional, per calendar month

Code + 99425:  is used to report additional 30 minutes provided by the physician or other qualified health care professional per calendar month.

CPT Code 99426 : use this code when reporting the first 30 minutes of clinical staff time directed by the physician or other qualified health care provider

CPT Code + 99427:  is used to report each additional 30 minutes of clinical staff time directed by the physician or other qualified health care provider.

To assess potential coding issues in your data for chronic and complex care management, it is recommended to use the following criteria within the Query Tool:

• • • Professional > Lines > Time Period of One (1) year
    • Specialties: Internal Medicine, Family Practice, Geriatric, Nurse Practitioners, Physician Assistants
    • Select Procedure Code > Custom Editor > 99490, 99439, 99491,  99437, 99487, or 99489
    • Select Diagnosis Code > Custom Editor > ** NOT @ (using this format will return claim lines for the selected codes billed with only a single diagnosis)
    • Select Provider Payment Received > Within this range > Minimum 1

If you find that you have payments for complex or chronic care management for a single diagnosis you should consider a documentation review to ensure the documentation supports the use of the code and time requirements.

References:

1. Center for Medicare and Medicaid Services (CMS.gov)
    https://www.cms.gov/files/document/chronic-care-management-faqs.pdf
2. Medicare Learning Network
   https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf
3. Chronic Conditions Data and Statistics
   https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Chronic-Conditions/CC_Main

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